1CM - COVID-19 Vaccination Request Form
This vaccination request form is for any persons within an eligible category to receive the vaccine:
1. Healthcare workers in clinical settings (e.g nurses, physicians, EMS, laboratory technicians, environmental services)
2. Staff and residents of long-term care facilities
3. All law enforcement and fire personnel (including volunteer departments)
4. Adults aged 65 and older (and their caregivers as applicable)
We appreciate your patience.
1st Care Management is currently scheduling appointments based on fulfillment of criteria for Phase 1A+. We will email you your scheduled date and time for vaccination, once it has been confirmed.
Please note that this form is only for one patient. If you're registering multiple, please fill the form separately for each patient. Please note that this form submission, by itself, is not a confirmation of an appointment.
Pick a statement from the list below that applies to you.
I am a Healthcare Provider or Worker
I am a Resident of a Long-Term Care Facility
I am a First Responder (law enforcement, EMS, fire personnel)
I am 65 years or older, or a caregiver of someone who is 65 years or older
None of the above apply to me
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This form was created inside of 1ST CARE MANAGEMENT.